Detection and Characterization of Musculoskeletal Cancer Using Whole-Body Magnetic Resonance Imaging.

Whole-body magnetic resonance imaging (WB-MRI) is gradually being integrated into clinical pathways for the detection, characterization, and staging of malignant tumors including those arising in the musculoskeletal (MSK) system. Although further developments and research are needed, it is now recognized that WB-MRI enables reliable, sensitive, and specific detection and quantification of disease burden, with clinical applications for a variety of disease types and a particular application for skeletal involvement. Advances in imaging techniques now allow the reliable incorporation of WB-MRI into clinical pathways, and guidelines recommending its use are emerging. This review assesses the benefits, clinical applications, limitations, and future capabilities of WB-MRI in the context of other next-generation imaging modalities, as a qualitative and quantitative tool for the detection and characterization of skeletal and soft tissue MSK malignancies.

Whole body MRI (WB-MRI) assessment of metastatic spread in prostate cancer: Therapeutic perspectives on targeted management of oligometastatic disease.

OBJECTIVES: To determine the proportion of prostate cancer (PCa) patients with oligometastatic disease (≤3 synchronous lesions) using whole body magnetic resonance imaging with diffusion-weighted imaging (WB-MRI/DWI). To determine the proportion of patients with nodal disease confined within currently accepted target areas for extended lymph node dissection (eLND) and pelvic external beam radiation therapy (EBRT). SUBJECTS AND METHODS: Two radiologists reviewed WB-MRI/DWI studies in 96 consecutive newly diagnosed metastatic PCa patients; 46 patients with newly diagnosed castration naive PCa (mHNPC) and 50 patients with first appearance of metastasis during monitoring for non-metastatic castration resistant PCa (M0 to mCRPC). The distribution of metastatic deposits was assessed and the proportions of patients with oligometastatic disease and with LN metastases located within eLND and EBRT targets were determined. RESULTS: Twenty-eight percent of mHNPC and 50% of mCPRC entered the metastatic disease with ≤3 sites. Bone metastases (BM) were identified in 68.8% patients; 71.7% of mHNPC and 66% mCRPC patients. Most commonly involved areas were iliac bones and lumbar spine. Enlarged lymph nodes (LN) were detected in 68.7% of patients; 69.6% of mHNPC and 68.0% of mCRPC. Most commonly involved areas were para-aortic, inter-aortico-cava, and external iliac areas. BM and LN were detected concomitantly in 41% of mHNPC and 34% of mCRPC. Visceral metastases were detected in 6.7%. Metastatic disease was confined to LN located within the accepted boundaries of eLND or pelvic EBRT target areas in only ≤25% and ≤30% of patients, respectively. CONCLUSIONS: Non-invasive mapping of metastatic landing sites in PCa using WB-MRI/DWI shows that 28% of the mHNPC patients, and 52% of the mCRPC can be classified as oligometastatic, thus challenging the concept of metastatic targeted therapy. More than two thirds of metastatic patients have LN located outside the usually recommended targets of eLND and pelvic EBRT. Prophylactic or salvage treatments of these sole areas in patients with high-risk prostate cancer may not prevent the emergence of subsequent metastases. Prostate 76:1024-1033, 2016. © 2016 Wiley Periodicals, Inc.

Whole-body 3D T1-weighted MR imaging in patients with prostate cancer: feasibility and evaluation in screening for metastatic disease.

PURPOSE: To develop and assess the diagnostic performance of a three-dimensional (3D) whole-body T1-weighted magnetic resonance (MR) imaging pulse sequence at 3.0 T for bone and node staging in patients with prostate cancer. MATERIALS AND METHODS This prospective study was approved by the institutional ethics committee; informed consent was obtained from all patients. Thirty patients with prostate cancer at high risk for metastases underwent whole-body 3D T1-weighted imaging in addition to the routine MR imaging protocol for node and/or bone metastasis screening, which included coronal two-dimensional (2D) whole-body T1-weighted MR imaging, sagittal proton-density fat-saturated (PDFS) imaging of the spine, and whole-body diffusion-weighted MR imaging. Two observers read the 2D and 3D images separately in a blinded manner for bone and node screening. Images were read in random order. The consensus review of MR images and the findings at prospective clinical and MR imaging follow-up at 6 months were used as the standard of reference. The interobserver agreement and diagnostic performance of each sequence were assessed on per-patient and per-lesion bases. RESULTS: The signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were significantly higher with whole-body 3D T1-weighted imaging than with whole-body 2D T1-weighted imaging regardless of the reference region (bone or fat) and lesion location (bone or node) (P < .003 for all). For node metastasis, diagnostic performance (area under the receiver operating characteristic curve) was higher for whole-body 3D T1-weighted imaging (per-patient analysis; observer 1: P < .001 for 2D T1-weighted imaging vs 3D T1-weighted imaging, P = .006 for 2D T1-weighted imaging + PDFS imaging vs 3D T1-weighted imaging; observer 2: P = .006 for 2D T1-weighted imaging vs 3D T1-weighted imaging, P = .006 for 2D T1-weighted imaging + PDFS imaging vs 3D T1-weighted imaging), as was sensitivity (per-lesion analysis; observer 1: P < .001 for 2D T1-weighted imaging vs 3D T1-weighted imaging, P < .001 for 2D T1-weighted imaging + PDFS imaging vs 3D T1-weighted imaging; observer 2: P < .001 for 2D T1-weighted imaging vs 3D T1-weighted imaging, P < .001 for 2D T1-weighted imaging + PDFS imaging vs 3D T1-weighted imaging). CONCLUSION: Whole-body MR imaging is feasible with a 3D T1-weighted sequence and provides better SNR and CNR compared with 2D sequences, with a diagnostic performance that is as good or better for the detection of bone metastases and better for the detection of lymph node metastases.

One-step TNM staging of high-risk prostate cancer using magnetic resonance imaging (MRI): toward an upfront simplified "all-in-one" imaging approach?

BACKGROUND: Multiparametric magnetic resonance imaging (mpMRI) is the standard for local prostate cancer (PCa) staging. Whole-body MRI (wbMRI) has shown capabilities for metastatic screening. This study assesses the feasibility and value of an all-in-one AJCC TNM staging of PCa during a unique MRI session combining mpMRI and wbMRI. METHODS: Thirty consecutive patients with "high-risk" PCa prospectively underwent mpMRI of the prostate and wbMRI, in addition to (99m) Tc bone scan (BS), completed with standard X-rays (±TXR) and contrast enhanced CT for distant staging. For the statistical analysis, a "best valuable comparator" (BVC) combining a panel review of all available baseline and follow-up imaging, biological, and clinical data was used to adjudicate lymph node and bone metastatic status. RESULTS: Prostate mpMRI was analyzed using ESUR guidelines. Sensitivity of BS ± TXR combined with CT and of wbMRI for detecting metastases (bones or nodes) was 85% and 100%, respectively, and specificity was 88% and 100%, respectively. For the overall staging of the patients as being either N0M0 or having disease extension beyond the prostate, wbMRI was superior to the combination of BS and CT (improvement in all ROC characteristics and of AUC by 13.6% (95% CI: +0.7% to +26.5%, P = 0.039)). The main limitation is the limited number of patients. CONCLUSIONS: AJCC M and N staging using wbMRI is feasible during the same imaging session as mpMRI performed for T staging, in less then one hour. wbMRI outperforms BS ± TXR and abdomino-pelvic CT work up for discriminating subsets of patients with or without distant spread of the cancer.

Novel imaging techniques reshape the landscape in high-risk prostate cancers.

PURPOSE OF REVIEW: High-risk prostate cancers (PCa), that is, those with prostate-specific antigen greater than 20 ng/dl, Gleason Score of at least 8, or extraprostatic spread, are nowadays commonly treated by surgery and radiotherapy combined with a fixed period of systemic treatment. Implementing these strategies requires an exhaustive assessment of metastatic spread. This review addresses the latest development in integrated imaging techniques. RECENT FINDINGS: In contrast to the progress that has been made in PCa treatment, diagnostic strategies have not much evolved. Most guidelines still recognize (99m)Tc bone scintigraphy and computed tomography (CT) as cornerstone modalities to assess metastatic spread in bones and lymph nodes. Therefore, modern imaging techniques should primarily focus on these two targets. PET with various tracers, including (11)C or (18)F-choline and (18)F-sodium fluoride, and MRI with or without diffusion-weighted imaging are competing to supplant bone scan and CT scan as reference imaging techniques. This review focuses on the latest development of these techniques and analyses their potential impact in everyday urology practice. SUMMARY: Although certain hurdles remain, PET and whole-body MRI have the ability to supplant (99m)Tc bone scan and CT as upfront test to assess metastatic spread in high-risk PCa.

Sternal cleft: prenatal multimodality imaging.

Sternal clefts have been reported sporadically, but there are no reports describing complete investigations of the malformation. We describe a child with isolated inferior sternal cleft diagnosed at 33 weeks of gestation and thoroughly investigated by prenatal US, MRI and CT and preoperative US. Our report highlights the importance of accurate and in-depth investigation by multimodality imaging that allows detection of accompanying serious anomalies and, hence, forms the basis for informed parental counselling and for postnatal interdisciplinary care.